DBPR ABT-6031 – Division of Alcoholic Beverages and Tobacco Request for Withdrawal of
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL
1940 North Monroe Street
Tallahassee, FL 32399-0783
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation or your local district office. Please submit your
completed application to your local district office. This application may be submitted by mail, through
appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be
found on AB&T’s page of the DBPR web site at the link provided below.
SECTION 1 - APPLICATION INFORMATION
I request the withdrawal of the following application:
Temporary Permit Number
Location Address (Street and Number)
Is the temporary permit attached to this application?
SECTION 2 - AFFIDAVIT OF APPLICANT
I, the undersigned individual, or if a corporation for itself, its officers and directors, hereby swear or affirm
that I am duly authorized to make the above request.
I swear under oath or affirmation under penalty of perjury as provided in Sections 559.791, 562.45 and
837.06, Florida Statutes, that the foregoing information is true and correct.
The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged
Before me this _______Day of____________, 20____, By___________________________________
who is ( ) personally known to me OR ( ) who produced ____________________________ as
________________________________________________ Commission Expires:____________________